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Kalmi G, Nguyen Y, Amarger S, Aubineau M, Bibes B, Blanchard-Delaunay C, Boccon-Gibod I, Bouillet L, Coppo P, Dalmas MC, Debord-Peguet S, Defendi F, Demoreuil C, Du-Thanh A, Gayet S, Hadjadj J, Jeandel PY, Launay D, Ly KH, Avoy CM, Niault M, Ollivier Y, Pelletier F, Porneuf M, Roos-Weil D, Fain O, Gobert D. Efficacy and Safety of Rituximab-Based Treatments in Angioedema With Acquired C1-Inhibitor Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:212-222. [PMID: 37844846 DOI: 10.1016/j.jaip.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/28/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Angioedema (AE) due to acquired C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is related to excessive consumption of C1-INH or to anti-C1-INH antibodies, and is frequently associated with lymphoproliferative syndromes or monoclonal gammopathies. Standard of care for prophylactic treatment in this condition is not established. Rituximab may be effective to prevent attacks, especially if the lymphoid hemopathy is controlled, but data are scarce. OBJECTIVE To evaluate efficacy of rituximab in AAE-C1-INH. METHODS A retrospective multicenter study was carried out in France, including patients with AAE-C1-INH treated with rituximab between April 2005 and July 2019. RESULTS Fifty-five patients with AAE-C1-INH were included in the study, and 23 of them had an anti-C1-INH antibody. A lymphoid malignancy was identified in 39 patients, and a monoclonal gammopathy in 9. There was no associated condition in 7 cases. Thirty patients received rituximab alone or in association with chemotherapy (n = 25). Among 51 patients with available follow-up, 34 patients were in clinical remission and 17 patients had active AE after a median follow-up of 3.9 years (interquartile range, 1.5-7.7). Three patients died. The presence of anti-C1-INH antibodies was associated with a lower probability of AE remission (hazard ratio, 0.29 [95% CI, 0.12-0.67]; P = .004). Relapse was less frequent in patients with lymphoma (risk ratio, 0.27 [95% CI, 0.09-0.80]; P = .019) and in patients treated with rituximab and chemotherapy (risk ratio, 0.31 [95% CI, 0.12-0.79]; P = .014). CONCLUSIONS Rituximab is an efficient and well-tolerated therapeutic option in AE, especially in lymphoid malignancies and in the absence of detectable anti-C1-INH antibodies.
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Affiliation(s)
- Galith Kalmi
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France.
| | - Yann Nguyen
- Internal Medicine Department, Nord-Université Paris Cité, AP-HP, Hôpital Beaujon, Clichy-sous-Bois, France
| | - Stephanie Amarger
- Dermatology Department, University Hospital, Clermont-Ferrand, France
| | - Magali Aubineau
- Internal Medicine Department, Hospices Civils de Lyon, Lyon, France
| | - Beatrice Bibes
- Internal Medicine Department, Saint Grégoire Hospital, Rennes, France
| | | | - Isabelle Boccon-Gibod
- Internal Medicine Department, French National Reference Center for Angioedema (CREAK), Grenoble University Hospital, Grenoble, France
| | - Laurence Bouillet
- Internal Medicine Department, French National Reference Center for Angioedema (CREAK), Grenoble University Hospital, Grenoble, France; University Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France; Internal Medicine Department, University Hospital La Tronche, Grenoble, France
| | - Paul Coppo
- Hematology Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | | | | | - Federica Defendi
- Immunology Department, Grenoble University Hospital, Grenoble, France
| | - Claire Demoreuil
- Internal Medicine Department, La Cavale Blanche University Hospital, Brest, France
| | - Aurélie Du-Thanh
- Dermatology Department, Montpellier University Hospital, Montpellier, France
| | - Stephane Gayet
- Internal Medicine Department, La Timone University Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Jerôme Hadjadj
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | | | - David Launay
- Internal and Immunological Medicine Department, Lille Hospital, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille University, INSERM F-59000, Lille, France
| | - Kim Heang Ly
- Internal Medicine Department, Dupuytren University Hospital, Limoges, France
| | - Chloé Mc Avoy
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Mathilde Niault
- Hematology Department, Hôpital du Scorff-Lorient, Groupe Hospitalier Bretagne Sud, Lorient, France
| | - Yann Ollivier
- Medicine Department, Cote de Nacre University Hospital, Caen, France
| | - Fabien Pelletier
- Dermatology Department, Allergology Center, Besançon University Hospital, Besançon, France
| | - Marc Porneuf
- Hematology Department, Centre Hospitalier Yves le Foll, Saint-Brieuc, France (x)Hematology Department, Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | - Damien Roos-Weil
- Hematology Department, Centre Hospitalier Yves le Foll, Saint-Brieuc, France (x)Hematology Department, Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | - Olivier Fain
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Delphine Gobert
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
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Shah D, Rishi R. Acquired Angioedema and Chronic Lymphocytic Leukemia: Unraveling the Complex Interplay and Addressing Refractory Cases. Cureus 2023; 15:e50238. [PMID: 38192915 PMCID: PMC10773689 DOI: 10.7759/cureus.50238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/10/2024] Open
Abstract
Acquired angioedema (AAE) due to deficiency of a C1 esterase inhibitor (C1-INH; AAE-C1-INH) is a rare and potentially fatal syndrome characterized by recurrent episodes of angioedema without urticaria. Often underdiagnosed due to its rarity and mimicry of common allergic reactions, AAE-C1-INH is associated with lymphoproliferative disorders, necessitating early recognition for improved outcomes. We present a case of a 63-year-old male diagnosed with AAE-C1-INH and concurrent stage 0 chronic lymphocytic leukemia (CLL), a rarely documented association. Despite chemotherapy, the patient experienced persistent angioedema until C1 esterase inhibitor therapy was initiated. This case underscores the importance of screening for lymphoproliferative disorders in AAE-C1-INH patients and explores refractory cases, urging further research into mechanisms and treatment strategies.
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Affiliation(s)
- Divya Shah
- Internal Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, USA
| | - Radha Rishi
- Allergy and Immunology, Arizona Allergy Associates, Phoenix, USA
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Iuraşcu M, Balla Z, Pereira C, Andrási N, Varga L, Csuka D, Szilágyi Á, Tripolszki K, Khan S, Susnea I, Bauer P, Cozma C, Farkas H. Application of a dried blood spot based proteomic and genetic assay for diagnosing hereditary angioedema. Clin Transl Allergy 2023; 13:e12317. [PMID: 38006386 PMCID: PMC10668000 DOI: 10.1002/clt2.12317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/24/2023] [Accepted: 11/06/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Hereditary angioedema (HAE) with C1-inhibitor deficiency (C1-INH-HAE) is a rare disease caused by low level (type I) or dysfunction (type II) of the C1-inhibitor protein with subsequent reduction of certain complement protein levels. METHODS To develop and test the reliability of a two-tier method based on C1-INH and C4 quantitation followed by genetic analysis from dried blood spot (DBS) for establishing the diagnosis of C1-INH-HAE. C1-INH and C4 proteins have been quantified in human plasma using a classical immuno-assay and in DBS using a newly developed proteolytic liquid chromatography-mass spectrometry method. Genetic analysis was carried out as reported previously (PMID: 35386643) and by a targeted next-generation sequencing panel, multiplex ligation-dependent probe amplification and in some cases whole genome sequencing. RESULTS DBS quantification of C1-INH and C4 showed the same pattern as plasma, offering the possibility of screening patients with AE symptoms either locally or remotely. Genetic analysis from DBS verified each of the previously identified SERPING1 mutations of the tested C1-INH-HAE patients and revealed the presence of other rare variations in genes that may be involved in the pathogenesis of AE episodes. CONCLUSIONS C1-INH/C4 quantification in DBS can be used for screening of hereditary AE and DNA extracted from dried blood spots is suitable for identifying various types of mutations of the SERPING1 gene.
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Affiliation(s)
| | - Zsuzsanna Balla
- Department of Internal MedicineHungarian Angioedema Center of Reference and ExcellenceHaematology Semmelweis UniversityBudapestHungary
- HNO‐Praxis SchaffhausenSchaffhausenSwitzerland
| | | | - Noémi Andrási
- Department of Internal MedicineHungarian Angioedema Center of Reference and ExcellenceHaematology Semmelweis UniversityBudapestHungary
| | - Lilian Varga
- Department of Internal MedicineHungarian Angioedema Center of Reference and ExcellenceHaematology Semmelweis UniversityBudapestHungary
| | - Dorottya Csuka
- Department of Internal MedicineHungarian Angioedema Center of Reference and ExcellenceHaematology Semmelweis UniversityBudapestHungary
| | - Ágnes Szilágyi
- Department of Internal MedicineHungarian Angioedema Center of Reference and ExcellenceHaematology Semmelweis UniversityBudapestHungary
| | | | | | | | | | | | - Henriette Farkas
- Department of Internal MedicineHungarian Angioedema Center of Reference and ExcellenceHaematology Semmelweis UniversityBudapestHungary
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Liu Y, Fan G, He F, Tong H, Jiang C, Xu P, Wang J. An unusual case of acquired angioedema associated with monoclonal gammopathies of uncertain significance. Allergol Immunopathol (Madr) 2023; 51:29-32. [PMID: 37695227 DOI: 10.15586/aei.v51i5.795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/26/2023] [Indexed: 09/12/2023]
Abstract
Acquired angioedema (AAE) is a rare disease due to the C1 esterase inhibitor (C1-INH) deficiency. Clinically, its symptoms are similar to hereditary angioedema (HAE) with hereditary C1-INH deficiency. Both conditions have the potential to cause upper airway obstruction, which can be fatal in clinical practice and thus require intense attention. Here, we'd like to discuss the clinical presentation, diagnosis and follow up of a special case of AAE associated with monoclonal gammopathies of unknown significance (MGUS) with recurrent upper airway obstruction. The patient was regularly followed up after being discharged from our ward. Measurements of C3-C4 levels were carried out by a hematological test. Due to the rarity of such a disease, especially in Chinese people, relevant diagnosis methods are missing in this patient, so the patient was only diagnosed with AAE-C1-INH associated with MGUS clinically. The latest follow up showed that he still underwent recurrent upper airway obstruction; thus, he remained in a tracheostomy state due to a lack of proper medication prophylaxis and died eventually. This unusual case reminds emergency physicians to pay attention to such disease during clinical practice, and relevant diagnosis method should be improved.
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Affiliation(s)
- Yun Liu
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Guofeng Fan
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Fei He
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Hanwen Tong
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Chenxiao Jiang
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Peng Xu
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China; @163.com
| | - Jun Wang
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China; @163.com
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Perlot Q, Hermans C, Vekemans MC. Manifestations rares des gammapathies monoclonales : à propos de 2 cas et revue de la littérature. Rev Med Interne 2023:S0248-8663(23)00088-7. [PMID: 37005096 DOI: 10.1016/j.revmed.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/20/2023] [Accepted: 03/09/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Monoclonal gammopathies are common over the age of 50. Patients are usually asymptomatic. However, some patients present with secondary clinical manifestations, which are now grouped under the entity « Monoclonal Gammopathy of Clinical Significance » (MGCS). CASE REPORT Here, we report two rare cases of MGCS: an acquired von Willebrand syndrome (AvWS) and an acquired angioedema (AAE). CONCLUSION The discovery of a decrease in von Willebrand activity (vWF:RCo) or angioedema in a patient over 50 years of age, in the absence of a family history, should prompt a search for a hemopathy and in particular, a monoclonal gammopathy.
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Polai Z, Kajdacsi E, Cervenak L, Balla Z, Benedek S, Varga L, Farkas H. C1-inhibitor/C1-inhibitor antibody complexes in acquired angioedema due to C1-inhibitor deficiency. Orphanet J Rare Dis 2023; 18:24. [PMID: 36726161 PMCID: PMC9890765 DOI: 10.1186/s13023-023-02625-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Autoantibodies against C1-inhibitor (C1-INH-Ab) have a diagnostic value in acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE), even though antibodies can circulate in complexes, which can be undetectable by proven methods. Our aim was to measure C1-INH/C1-INH-Ab complexes (CAC) and investigate their connection to C1-INH-Ab and the changes in their titer over time. RESULTS 19 patients were diagnosed with C1-INH-AAE in the Hungarian Angioedema Center of Reference and Excellence; 79% of them had an underlying disease. Samples were examined with a newly developed in-house complex ELISA method. Patients with high C1-INH-Ab titer had a CAC titer which did not exceed the normal level and the ones with high CAC titer had a C1-INH-Ab titer which did not exceed the normal level. In case of those patients who had C1-INH-Ab and CAC of the same type of immunoglobulin, the increasing titer of C1-INH-Ab went together with the decreasing level of CAC and vice versa. CAC titer was already increased before the diagnosis of the underlying disease. CONCLUSIONS Free circulating and complex antibodies are in a dynamically changing equilibrium. CAC measurements can help to predict the development of an underlying disease. The efficiency of the treatment for underlying disease can be monitored by the decreasing CAC titers. Our results show that the CAC can be of important additional information besides the complement panel examination in case of C1-INH-AAE. Measurement of CAC is recommended to be done parallelly with C1-INH-Ab, so as to detect both free and bound antibodies.
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Affiliation(s)
- Zsofia Polai
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Szentkiralyi u. 46, Budapest, 1088 Hungary
| | - Erika Kajdacsi
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Laszlo Cervenak
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Balla
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Szentkiralyi u. 46, Budapest, 1088 Hungary
| | - Szabolcs Benedek
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Szentkiralyi u. 46, Budapest, 1088 Hungary
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Szentkiralyi u. 46, Budapest, 1088, Hungary.
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Polai Z, Balla Z, Benedek S, Kajdacsi E, Farkas H. Laryngeal angioedema caused by a rare disease – a case report. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2022. [DOI: 10.1016/j.cpccr.2022.100201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Grumach AS, Veronez CL, Csuka D, Farkas H. Angioedema Without Wheals: Challenges in Laboratorial Diagnosis. Front Immunol 2021; 12:785736. [PMID: 34956216 PMCID: PMC8694242 DOI: 10.3389/fimmu.2021.785736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Angioedema is a prevailing symptom in different diseases, frequently occurring in the presence of urticaria. Recurrent angioedema without urticaria (AE) can be hereditary (HAE) and acquired (AAE), and several subtypes can be distinguished, although clinical presentation is quite similar in some of them. They present with subcutaneous and mucosal swellings, affecting extremities, face, genitals, bowels, and upper airways. AE is commonly misdiagnosed due to restricted access and availability of appropriate laboratorial tests. HAE with C1 inhibitor defect is associated with quantitative and/or functional deficiency. Although bradykinin-mediated disease results mainly from disturbance in the kallikrein–kinin system, traditionally complement evaluation has been used for diagnosis. Diagnosis is established by nephelometry, turbidimetry, or radial immunodiffusion for quantitative measurement of C1 inhibitor, and chromogenic assay or ELISA has been used for functional C1-INH analysis. Wrong handling of the samples can lead to misdiagnosis and, consequently, mistaken inappropriate approaches. Dried blood spot (DBS) tests have been used for decades in newborn screening for certain metabolic diseases, and there has been growing interest in their use for other congenital conditions. Recently, DBS is now proposed as an efficient tool to diagnose HAE with C1 inhibitor deficiency, and its use would improve the access to outbound areas and family members. Regarding HAE with normal C1 inhibitor, complement assays’ results are normal and the genetic sequencing of target genes, such as exon 9 of F12 and PLG, is the only available method. New methods to measure cleaved high-molecular-weight kininogen and activated plasma kallikrein have emerged as potential biochemical tests to identify bradykinin-mediated angioedema. Validated biomarkers of kallikrein–kinin system activation could be helpful in differentiating mechanisms of angioedema. Our aim is to focus on the capability to differentiate histaminergic AE from bradykinin-mediated AE. In addition, we will describe the challenges developing specific tests like direct bradykinin measurements. The need for quality tests to improve the diagnosis is well represented by the variability of results in functional assays.
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Affiliation(s)
- Anete S Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitario Faculdade de Medicina ABC (FMABC), Santo Andre, Brazil
| | - Camila L Veronez
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, CA, United States.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, CA, United States
| | - Dorottya Csuka
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
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Wonnaparhown A, Stefanovic A, Lugar P, Hostetler HP. Acquired angioedema in B cell lymphoproliferative disease: A retrospective case series. Clin Exp Immunol 2021; 206:378-383. [PMID: 34586637 DOI: 10.1111/cei.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/02/2021] [Accepted: 09/22/2021] [Indexed: 01/08/2023] Open
Abstract
Acquired angioedema due to C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is rare and is associated with underlying lymphoproliferative diseases. C1-INH deficiency may be due to neoplastic over-consumption of C1-INH and the generation of anti-C1-INH autoantibodies. Uncovering an occult malignancy can lead to earlier oncology referral and improvement of angioedema after treatment of the underlying lymphoproliferative disorder. We characterized seven patients with C1-INH-AAE that highlights the importance of recognizing the association between C1-INH-AAE and underlying malignancy. In acute attacks, patients may be resistant to C1-INH therapy due to the presence of anti-C1-INH autoantibodies or rapid complement consumption, and may respond better to icatibant or ecallantide, which directly affect bradykinin. Treatment of the underlying malignancy also improves AAE-C1-INH symptoms and supports the role of lymphoproliferative B cells in AAE-C1-INH pathophysiology. Monitoring levels of C4, C1-INH function and level, and C1q may be predictive of AAE-C1-INH control and be used as surrogates for treatment efficacy. With close monitoring, low-dose danazol can be effective for long-term prophylaxis. Annual evaluation in AAE-C1-INH is recommended if an underlying malignancy is not found, as angioedema may precede the development of malignancy by several years. Our single-center study has aided in standardization of comprehensive AAE-C1-INH diagnosis, treatment, and monitoring strategies towards future therapeutic clinical trials.
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Affiliation(s)
- Alex Wonnaparhown
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Alexandra Stefanovic
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Patricia Lugar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Haley P Hostetler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
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10
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Roy S, Konala VM, Kyaw T, Chakraborty S, Naramala S, Gayam V, Adapa S, Bose S. An Unusual Case of Acquired Angioedema and Monoclonal Gammopathy of Renal Significance in a Middle-Aged Caucasian Female. J Investig Med High Impact Case Rep 2021; 8:2324709620912096. [PMID: 32167383 PMCID: PMC7074490 DOI: 10.1177/2324709620912096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Acquired angioedema due to deficiency of C1 esterase inhibitor is also called acquired angioedema and is abbreviated as C1INH-AAE. It is a rare syndrome of recurrent episodes of angioedema, without urticaria, and in some patients, it is associated with B-cell lymphoproliferative disorders. Kidney involvement is rare in this condition. The monoclonal immunoglobulin secreted by a nonmalignant or premalignant B-cell or plasma cell clone, causing renal damage that represents a group of disorders which are termed as monoclonal gammopathy of renal significance (MGRS). In this article, we report a rare case of acquired C1 esterase deficiency angioedema and acute kidney injury with renal biopsy-proven MGRS. We present a 64-year-old Caucasian woman who presented with 2 weeks of recurring urticaria and new onset of acute kidney injury. She was diagnosed with monoclonal gammopathy–associated proliferative glomerulopathy through kidney biopsy, and serological workup came back positive for C1 esterase deficiency, implying acquired angioedema. Acquired angioedema is a rare disease with systemic involvement. Recurrent allergic manifestations and acute kidney injury should prompt MGRS as a differential.
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Affiliation(s)
- Sasmit Roy
- Lynchburg Nephrology Physicians, Lynchburg, VA, USA
| | | | - Thurein Kyaw
- Lynchburg Nephrology Physicians, Lynchburg, VA, USA
| | | | | | - Vijay Gayam
- Interfaith Medical Center, Brooklyn, NY, USA
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Shi Y, Wang C. Where we are with acquired angioedema due to C1 inhibitor deficiency: A systematic literature review. Clin Immunol 2021; 230:108819. [PMID: 34358691 DOI: 10.1016/j.clim.2021.108819] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
Acquired angioedema due to C1 inhibitor deficiency (C1-INH-AAE) is a rare disease characterized by adult-onset recurrent non-urticarial angioedema with low levels of C1-INH. It is associated with lymphoproliferative disorders, and treatments are off-label with variable success. We conducted a systematic literature review to include patients with C1-INH-AAE identified in PubMed and Embase databases between January 2006 and February 2021. Clinical features of these patients were summarized, and factors associated with disease remission were explored. A total of 121 patients were included in the current study with a median age at diagnosis of 64 years and 45.5% being male. An associated disease was recorded in 94 patients (77.7%), and lymphoproliferative disorder was the most reported (59/94, 62.8%). Anti-C1-INH autoantibodies were present in 45 of 71 patients (63.4%). Factors impacting disease remissions included age (odds ratio [OR] 0.951, 95% confidence interval [CI] 0.909-0.994, p = 0.027), male (OR 0.327, 95% CI 0.124-0.866, p = 0.025), presence of monoclonal gammopathy (OR 0.133, 95% CI 0.041-0.429, p = 0.001), requirement of specific on-demand treatment (OR 0.216, 95% CI 0.066-0.709, p = 0.012) and rituximab use (OR 2.865, 95% CI 1.038-7.911, p = 0.042). A total of nine patients (7.4%) died at last follow up and most were unrelated to C1-INH-AAE. Our results imply that C1-INH-AAE is primarily associated with underlying B or plasma cell abnormalities, and clone-directed therapies could be promising options for its long-term management.
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Affiliation(s)
- Yiyun Shi
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chen Wang
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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Abstract
Abdominal pain is one of the most common conditions leading people to the emergency department. An uncommon but well described cause of abdominal pain is angioedema of the gastrointestinal tract due to recurrent angioedema without wheals. Abdominal involvement is very common in hereditary angioedema (HAE), but it is also described in acquired angioedema and allergic forms. In patients with HAE, the involvement of gastrointestinal tract with resultant abdominal pain occurs in 43-93% of cases. Attacks can involve the entire gastrointestinal tract, such as the oropharynx, small intestine, colon, liver, or pancreas. Pain is the most common gastrointestinal symptom, and it may occur for many years even without cutaneous or respiratory symptoms. The case report we included in this article emphasizes the importance of accurate evaluation of personal and family history in patients with a long history of acute, severe, and unexplained abdominal pain, and it gives an example of how diagnostic delay may be longer if gastroenterological symptoms are the predominant clinical presentation. Furthermore, sometimes the simultaneous presence of concomitant gastrointestinal disorders and HAE may cause difficulties in differential diagnosis. Gastroenterologists and other physicians should add HAE to their list of potential causes of unexplained abdominal pain. The initiation of appropriate prophylaxis and treatment will prevent needless suffering and useless surgical and medical procedures.
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13
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Willrich MAV, Braun KMP, Moyer AM, Jeffrey DH, Frazer-Abel A. Complement testing in the clinical laboratory. Crit Rev Clin Lab Sci 2021; 58:447-478. [PMID: 33962553 DOI: 10.1080/10408363.2021.1907297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The complement system is the human's first line of defense against microbial pathogens because of its important housekeeping and infection/inflammation roles. It is composed of a series of soluble and cell-bound proteins that are activated in a cascade effect, similar to the coagulation pathways. There are different pattern recognizing molecules that activate the complement system in response to stimuli or threats, acting through three initiation pathways: classical, lectin, and alternative. All three activation pathways converge at the C3 component and share the terminal pathway. The main outputs of the complement system action are lytic killing of microbes, the release of pro-inflammatory anaphylatoxins, and opsonization of targets. Laboratory testing is relevant in the setting of suspected complement deficiencies, as well as in the emerging number of diseases related to dysregulation (over-activation) of complement. Most common assays measure complement lytic activity and the different complement component concentrations. Specialized testing includes the evaluation of autoantibodies against complement components, activation fragments, and genetic studies. In this review, we cover laboratory testing for complement and the conditions with complement involvement, as well as current challenges in the field.
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Affiliation(s)
| | - Karin M P Braun
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - David H Jeffrey
- Exsera Biolabs, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ashley Frazer-Abel
- Exsera Biolabs, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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14
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Pólai Z, Balla Z, Andrási N, Kőhalmi KV, Temesszentandrási G, Benedek S, Varga L, Farkas H. A follow-up survey of patients with acquired angioedema due to C1-inhibitor deficiency. J Intern Med 2021; 289:547-558. [PMID: 33215769 DOI: 10.1111/joim.13182] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) is a rare form of bradykinin-mediated angioedema. It is diagnosed by complement testing; its treatment consists of the management of angioedema (AE) attacks and of underlying disease. OBJECTIVE Evaluate the results of the clinical follow-up of patients with C1-INH-AAE. METHODS Between 1999 and 2020, 3938 patients with angioedema were evaluated, and 17 diagnosed with acquired C1-INH deficiency were followed-up. RESULTS Mean age of the 17 patients was 61 years at diagnosis. In 33%, ACE inhibitors provoked AE attacks. Autoantibodies against C1-INH were detected in 10 patients at diagnosis and in a further patient during follow-up. The AE attacks involved the skin in 70.6%, the upper airways in 41.2% and the tongue/lip in 52.9% of patients. Twelve of the 17 patients had an underlying condition, mainly (n = 11) lymphoproliferative disease. In 10 patients diagnosed with a haematological disorder, AAE symptoms preceded the onset of the latter. One patient has not experienced an AE attack since diagnosis. Twelve patients were treated for angioedema attacks, and 32% of the attacks required acute treatment. PdC1-INH was used to relieve AE attacks, and rituximab for the treatment of underlying disease (in six patients). Six patients had multiple AE attacks before any treatment. The symptom-free period increased in five patients after the on-demand administration of pdC1-INH concentrate and following treatment of the underlying disease in two patients. CONCLUSION Early diagnosis of C1-INH-AAE and underlying disease is indispensable to reduce disease burden by introducing appropriate, individualized treatment and regular follow-up.
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Affiliation(s)
- Zs Pólai
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Zs Balla
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - N Andrási
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - K V Kőhalmi
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Buda Hospital of the Hospitaller Order of Saint John of God, Rheumatology Center, Budapest, Hungary
| | - Gy Temesszentandrási
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Sz Benedek
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - L Varga
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - H Farkas
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
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15
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The Immunopathology of Complement Proteins and Innate Immunity in Autoimmune Disease. Clin Rev Allergy Immunol 2020; 58:229-251. [PMID: 31834594 DOI: 10.1007/s12016-019-08774-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The complement is a powerful cascade of the innate immunity and also acts as a bridge between innate and acquired immune defence. Complement activation can occur via three distinct pathways, the classical, alternative and lectin pathways, each resulting in the common terminal pathway. Complement activation results in the release of a range of biologically active molecules that significantly contribute to immune surveillance and tissue homeostasis. Several soluble and membrane-bound regulatory proteins restrict complement activation in order to prevent complement-mediated autologous damage, consumption and exacerbated inflammation. The crucial role of complement in the host homeostasis is illustrated by association of both complement deficiency and overactivation with severe and life-threatening diseases. Autoantibodies targeting complement components have been described to alter expression and/or function of target protein resulting in a dysregulation of the delicate equilibrium between activation and inhibition of complement. The spectrum of diseases associated with complement autoantibodies depends on which complement protein and activation pathway are targeted, ranging from autoimmune disorders to kidney and vascular diseases. Nevertheless, these autoantibodies have been identified as differential biomarkers for diagnosis or follow-up of disease only in a small number of clinical conditions. For some autoantibodies, a clear relationship with clinical manifestations has been identified, such as anti-C1q, anti-Factor H, anti-C1 Inhibitor antibodies and C3 nephritic factor. For other autoantibodies, the origin and the functional consequences still remain to be elucidated, questioning about the pathophysiological significance of these autoantibodies, such as anti-mannose binding lectin, anti-Factor I, anti-Factor B and anti-C3b antibodies. The detection of autoantibodies targeting complement components is performed in specialized laboratories; however, there is no consensus on detection methods and standardization of the assays is a real challenge. This review summarizes the current panorama of autoantibodies targeting complement recognition proteins of the classical and lectin pathways, associated proteases, convertases, regulators and terminal components, with an emphasis on autoantibodies clearly involved in clinical conditions.
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16
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Angioedema. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society (PTD) and Polish Society of Allergology (PTA). Postepy Dermatol Alergol 2020; 37:445-451. [PMID: 32994763 PMCID: PMC7507159 DOI: 10.5114/ada.2020.98226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 11/17/2022] Open
Abstract
Angioedema is a non-inflammatory oedema of the subcutaneous tissue and/or mucosal membranes. It most commonly coexists with urticaria wheals and is considered to be a deep form of urticaria. Less commonly, it occurs in isolation and can take two basic forms: acquired angioedema and hereditary angioedema. Currently, there are 4 defined types of acquired angioedema and 7 types of hereditary angioedema. Treatment of angioedema depends on its form and etiological factors. Especially the genetic form, i.e. hereditary angioedema, is a considerable challenge for medical specialists, particularly dermatologists and allergists.
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17
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Singh A, Motilal Nehru V, Peace D. Refractory acquired angioedema in chronic lymphocytic leukemia. Leuk Lymphoma 2020; 61:3280-3281. [PMID: 32842805 DOI: 10.1080/10428194.2020.1804559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Avani Singh
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Vijeyaluxmy Motilal Nehru
- Department of Medicine, Division of Hematology and Oncology, University of Illinois at Chicago, Chicago, IL, USA
| | - David Peace
- Department of Medicine, Division of Hematology and Oncology, University of Illinois at Chicago, Chicago, IL, USA
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18
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Acquired Angioedema: A Rare Manifestation of Angioimmunoblastic T Cell Lymphoma. Indian J Otolaryngol Head Neck Surg 2019; 71:96-99. [PMID: 31741940 DOI: 10.1007/s12070-017-1122-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 04/04/2017] [Indexed: 10/19/2022] Open
Abstract
The clinical presentation except age of onset is similar in different types of angioedema. A lymphoproliferative disorder like angioimmunoblastic T cell lymphoma (AITL) rarely presents with symptoms of angioedema. We present extremely rare case of elderly male with recurrent tongue swelling, pruritus with normal levels of complements and C1 esterase inhibitor protein featuring as acquired angioedema, a rare manifestation of AITL. Initial response to corticosteroids may be misleading and occurs as a result of immunosuppression of AITL. High index of suspicion may prompt need for histopathological diagnosis of lymph node biopsy. Definitive chemotherapeutic treatment may achieve long term remission.
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19
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Skattum L. Clinical Complement Analysis-An Overview. Transfus Med Rev 2019; 33:207-216. [PMID: 31672339 DOI: 10.1016/j.tmrv.2019.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
The complement system plays an important role in varying types of disease, ranging from inflammatory and autoimmune disorders to immune deficiency states. In addition, new settings have emerged where complement analysis is of interest to monitor complement-directed therapy and aid identification of transplant complications. Therefore, it is critical that clinical laboratories offer optimized and timely complement analysis. This review presents a comprehensive overview of the most important complement analysis methods that are currently used. It also points to some areas within complement diagnostics where development is needed, for example, regarding certain analytes for which practical methods suitable for the routine laboratory are lacking. Furthermore, it contains a more detailed discussion on complement autoantibody assessment. The list of analyses providing clinically valuable information includes analysis of complement function, quantification of individual complement components and complement activation fragments, identification of autoantibodies to complement, as well as genetic complement analyses. There is still a shortage of commercially available methods suitable for high-throughput screening of complement deficiency and for assessment of complement activation, but development is under way. There is also ongoing work within the complement community to improve standardization of measurements, and recently, an extensive quality assurance program has been initiated.
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Affiliation(s)
- Lillemor Skattum
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University, and Clinical Immunology and Transfusion Medicine, Region Skåne, Lund, Sweden.
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20
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López-Lera A, Garrido S, Nozal P, Skatum L, Bygum A, Caballero T, López Trascasa M. Serum complexes between C1INH and C1INH autoantibodies for the diagnosis of acquired angioedema. Clin Exp Immunol 2019; 198:341-350. [PMID: 31397881 DOI: 10.1111/cei.13361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2019] [Indexed: 11/26/2022] Open
Abstract
Acquired angioedema due to C1-inhibitor (C1INH) deficiency (AAE) is caused by secondary C1INH deficiency leading to bradykinin-mediated angioedema episodes. AAE typically presents in adulthood and is associated with B cell lymphoproliferation. Anti-C1INH autoantibodies (antiC1INHAbs) are detectable in a subset of AAE cases and considered a hallmark of the disease. When free antiC1INHAbs and malignant tumors are not detectable, diagnosis relies on the finding of low C1INH levels and/or function, lack of family history and SERPING1 mutations, age at onset and low or undetectable C1q levels, none of which is specific for AAE. We tested the diagnostic value of a novel enzyme-linked immunosorbent assay (ELISA) for the detection of circulating complexes between C1INH and antiC1INHAbs (C1INH-antiC1INHAb) in the serum of 20 European AAE patients characterized on the basis of their complement levels and function. Free antiC1INHAbs were detected in nine of 20 patients [six of immunoglobulin (Ig)G class, two of IgM class and one simultaneously presenting IgG and IgM classes], whereas C1INH-antiC1INHAb complexes were found in 18 of 20 of the AAE cases, regardless of the presence or absence of detectable free anti-C1INHAbs. Of note, nine of 20 patients showed negative free antiC1INHabs, but positive C1INH-antiC1INHAb complexes in their first measurement. In the cohort presented, IgM-class C1INH-antiC1INHAb are specifically and strongly associated with low C1q serum levels. Detection of C1INH-antiC1-INHAbs provides an added value for AAE diagnosis, especially in those cases in whom no free anti-C1INH antibodies are detected. The link between IgM-class C1INH-antiC1INHAb complexes and C1q consumption could have further implications for the development of autoimmune manifestations in AAE.
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Affiliation(s)
- A López-Lera
- Instituto de Investigación Sanitaria del Hospital La Paz (IdiPaz), Madrid, Spain.,Centre for Biomedical Network Research on Rare Diseases (CIBERER) U-754, Hospital Universitario La Paz, Madrid, Spain
| | - S Garrido
- Centre for Biomedical Network Research on Rare Diseases (CIBERER) U-754, Hospital Universitario La Paz, Madrid, Spain.,Immunology Unit, Hospital Universitario La Paz, Madrid, Spain
| | - P Nozal
- Centre for Biomedical Network Research on Rare Diseases (CIBERER) U-754, Hospital Universitario La Paz, Madrid, Spain.,Immunology Unit, Hospital Universitario La Paz, Madrid, Spain
| | - L Skatum
- Clinical Immunology and Transfusion Medicine, Office for Medical Services, Lund, Sweden
| | - A Bygum
- National HAE Centre, Odense University Hospital, Denmark
| | - T Caballero
- Instituto de Investigación Sanitaria del Hospital La Paz (IdiPaz), Madrid, Spain.,Centre for Biomedical Network Research on Rare Diseases (CIBERER) U-754, Hospital Universitario La Paz, Madrid, Spain.,Department of Allergy, Hospital Universitario La Paz, Madrid, Spain
| | - M López Trascasa
- Instituto de Investigación Sanitaria del Hospital La Paz (IdiPaz), Madrid, Spain.,Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
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21
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Hereditary Angioedema: Insights into inflammation and allergy. Mol Immunol 2019; 112:378-386. [PMID: 31279849 DOI: 10.1016/j.molimm.2019.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 11/21/2022]
Abstract
Hereditary Angioedema (HAE) is a rare autosomal recessive bradykinin (BK)-mediated disease characterized by local episodes of non-pitting swelling. Initially considered a complement-mediated disease, novel pathogenic mechanisms uncovered in the last decade have revealed new HAE-associated genes and tight physiological relationships among complement, contact, coagulation, fibrinolysis and inflammation. Uncontrolled production of BK due to inefficient regulation of the plasma contact system, increased activity of contact and coagulation factors or a deficient regulation of BK receptor-triggered intracellular signalling are on the basis of HAE pathology. In this new scenario, HAE can result from different mechanisms that may generate distinct clinical phenotypes of the disease. This review focuses in the recent advances and unsolved challenges in our comprehension of this ever increasingly complex pathology.
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22
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Ekdahl KN, Persson B, Mohlin C, Sandholm K, Skattum L, Nilsson B. Interpretation of Serological Complement Biomarkers in Disease. Front Immunol 2018; 9:2237. [PMID: 30405598 PMCID: PMC6207586 DOI: 10.3389/fimmu.2018.02237] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/10/2018] [Indexed: 01/07/2023] Open
Abstract
Complement system aberrations have been identified as pathophysiological mechanisms in a number of diseases and pathological conditions either directly or indirectly. Examples of such conditions include infections, inflammation, autoimmune disease, as well as allogeneic and xenogenic transplantation. Both prospective and retrospective studies have demonstrated significant complement-related differences between patient groups and controls. However, due to the low degree of specificity and sensitivity of some of the assays used, it is not always possible to make predictions regarding the complement status of individual patients. Today, there are three main indications for determination of a patient's complement status: (1) complement deficiencies (acquired or inherited); (2) disorders with aberrant complement activation; and (3) C1 inhibitor deficiencies (acquired or inherited). An additional indication is to monitor patients on complement-regulating drugs, an indication which may be expected to increase in the near future since there is now a number of such drugs either under development, already in clinical trials or in clinical use. Available techniques to study complement include quantification of: (1) individual components; (2) activation products, (3) function, and (4) autoantibodies to complement proteins. In this review, we summarize the appropriate indications, techniques, and interpretations of basic serological complement analyses, exemplified by a number of clinical disorders.
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Affiliation(s)
- Kristina N Ekdahl
- Rudbeck Laboratory C5:3, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Barbro Persson
- Rudbeck Laboratory C5:3, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Camilla Mohlin
- Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Kerstin Sandholm
- Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Lillemor Skattum
- Section of Microbiology, Immunology and Glycobiology, Department of Laboratory Medicine, Clinical Immunology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Bo Nilsson
- Rudbeck Laboratory C5:3, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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23
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[Acquired C1 esterase inhibitor deficiency via bradykinin-mediated angioedema: Four cases]. Ann Dermatol Venereol 2018; 145:598-602. [PMID: 29673745 DOI: 10.1016/j.annder.2018.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/25/2017] [Accepted: 02/13/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acquired C1-esterase inhibitor (C1-INH) deficiency angioedema (C1-INH-AAE) is a form of bradykinin-mediated angioedema. This rare disorder is due to acquired consumption of C1-INH, hyperactivation of the classic pathway of human complement, and potentially fatal recurrent angioedema symptoms. Clinical symptoms of C1-INH-AAE are very similar to those of hereditary angioedema (HAE) but usually appear after the fourth decade of life and induce abdominal pain less frequently. Laboratory tests are essential in establishing the diagnosis with low levels or abnormal structure and function of C1-INH. Most patients present C1-INH autoantibodies. Furthermore, C1q is reduced in AAE, contrary to HAE. The long-term prognosis is determined by associated hematologic malignancies. PATIENTS AND METHODS We report 4 cases of C1-INH-AAE associated with lymphoproliferative disorders referred to the Reference Centre for Angioedema of Besançon, France. The patients were aged between 60 and 77 years. C1 INH antibodies were found in three patients. Symptoms were triggered by angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) in 3 patients. Hematologic malignancy was present at diagnosis (one case of chronic lymphoid leukemia) or was diagnosed during follow-up (one case of indolent marginal zone non-Hodgkin lymphoma and two cases of monoclonal gammopathy). DISCUSSION C1-INH-AAE induced by ACE inhibitors or ARBs may be associated with hematologic malignancies. This form of revelation does not necessarily indicate a diagnosis of ACE or ARBs angioedema, and screening should therefore be performed for C1 Inh and C1q. An underlying hematologic malignancy should be routinely sought and the long-term prognosis determined.
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24
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Csuka D, Veszeli N, Varga L, Prohászka Z, Farkas H. The role of the complement system in hereditary angioedema. Mol Immunol 2017; 89:59-68. [PMID: 28595743 DOI: 10.1016/j.molimm.2017.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/22/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
Hereditary angioedema (HAE) is a rare, but potentially life-threatening disorder, characterized by acute, recurring, and self-limiting edematous episodes of the face, extremities, trunk, genitals, upper airways, or the gastrointestinal tract. HAE may be caused by the deficiency of C1-inhibitor (C1-INH-HAE) but another type of the disease, hereditary angioedema with normal C1-INH function (nC1-INH-HAE) was also described. The patient population is quite heterogeneous as regards the location, frequency, and severity of edematous attacks, presenting large intra- and inter-individual variation. Here, we review the role of the complement system in the pathomechanism of HAE and also present an overview on the complement parameters having an importance in the diagnosis or in predicting the severity of HAE.
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Affiliation(s)
- Dorottya Csuka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - Nóra Veszeli
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
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25
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Abstract
Acquired angioedema due to C1-INH deficiency (C1-INH-AAE) can occur when there are acquired (not inherited) deficiencies of C1-INH. A quantitative or functional C1-INH deficiency with negative family history and low C1q is diagnostic of C1-INH-AAE. The most common conditions associated with C1-INH-AAE are autoimmunity and B-cell lymphoproliferative disorders. A diagnosis of C1-INH-AAE can precede a diagnosis of lymphoproliferative disease and confers an increased risk for developing non-Hodgkin lymphoma. Treatment focuses on symptom control with therapies that regulate bradykinin activity (C1-INH concentrate, icatibant, ecallantide, tranexamic acid, androgens) and treatment of any underlying conditions.
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Affiliation(s)
- Iris M Otani
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, UCSF Medical Center, 400 Parnassus Avenue, Box 0359, San Francisco, CA 94143, USA.
| | - Aleena Banerji
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Cox 201 Allergy Associates, Boston, MA 02114, USA
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26
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Wu MA, Perego F, Zanichelli A, Cicardi M. Angioedema Phenotypes: Disease Expression and Classification. Clin Rev Allergy Immunol 2017; 51:162-9. [PMID: 27113957 DOI: 10.1007/s12016-016-8541-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Due to marked heterogeneity of clinical presentations, comprehensive knowledge of angioedema phenotypes is crucial for correct diagnosis and choosing the appropriate therapeutic approach. One of the ways to a meaningful clinical distinction can be made between forms of angioedema occurring "with or without wheals." Angioedema with wheals (rash) is a hallmark of urticaria, either acute or chronic, spontaneous or inducible. Angioedema without wheals may still be manifested in about 10 % of patients with urticaria, but it may also occur as a separate entity. Several classifications of angioedema as part of urticaria were published over time, while a latest one, released in 2014 (HAWK group consensus, see below), provided a classification of all forms of "angioedema without wheals" distinct from urticaria, which will be the focus of the present review. At this time, the HAWK consensus classification is the best in terms of covering the pathophysiology, mediators involved, angioedema triggers, and clinical expression. According to this classification, three types of hereditary angioedema (genetic C1-INH deficiency, normal C1-INH with factor XII mutations, and unknown origin) and four types of acquired angioedema (C1-INH deficiency, related to ACE inhibitors intake, idiopathic histaminergic, and idiopathic non-histaminergic) are presented. We will review the distinctive clinical features of each phenotype in details.
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Affiliation(s)
- Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Francesca Perego
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy.
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27
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Gobert D, Paule R, Ponard D, Levy P, Frémeaux-Bacchi V, Bouillet L, Boccon-Gibod I, Drouet C, Gayet S, Launay D, Martin L, Mekinian A, Leblond V, Fain O. A nationwide study of acquired C1-inhibitor deficiency in France: Characteristics and treatment responses in 92 patients. Medicine (Baltimore) 2016; 95:e4363. [PMID: 27537564 PMCID: PMC5370791 DOI: 10.1097/md.0000000000004363] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Acquired angioedema (AAE) due to C1-inhibitor (C1INH) deficiency is rare. Treatment options for acute attacks are variable and used off-label. Successful treatment of the associated lymphoma with rituximab seems to prevent acute attacks in subjects with AAE. The aim of this study was to describe AAE manifestations, its associated diseases, and patients' responses to treatments in a representative cohort.A retrospective nationwide study was conducted in France. The inclusion criteria were recurrent angioedema attacks and an acquired decrease in functional C1INH <50% of the reference value.A total of 92 cases were included, with a median age at onset of 62 years. Facial edema and abdominal pain were the most frequent symptoms. Fifteen patients were hospitalized in the intensive care unit because of laryngeal edema, and 1 patient died. Anti-C1INH antibodies were present in 43 patients. The associated diseases were primarily non-Hodgkin lymphoma (n = 44, with 24 splenic marginal zone lymphomas) and monoclonal gammopathy of undetermined significance (n = 24). Three patients had myeloma, 1 had amyloid light-chain (of immunoglobulin) (AL) amyloidosis, 1 patient had a bronchial adenocarcinoma, and 19 patients had no associated disease. Icatibant relieved the symptoms in all treated patients (n = 26), and plasma-derived C1INH concentrate in 19 of 21 treated patients. Six patients experienced thromboembolic events under tranexamic acid prophylaxis. Rituximab prevented angioedema in 27 of 34 patients as a monotherapy or in association with chemotherapy. Splenectomy controlled AAE in 7 patients treated for splenic marginal zone lymphoma. After a median follow-up of 4.2 years, angioedema was on remission in 52 patients.AAE cases are primarily associated with indolent lymphoma-especially splenic marginal zone lymphoma-and monoclonal gammopathy of undetermined significance but not with autoimmune diseases or other conditions. Icatibant and plasma-derived C1INH concentrate control attacks; splenectomy and immunochemotherapy prevent angioedema in lymphoma setting.
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Affiliation(s)
- Delphine Gobert
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
- Correspondence: Delphine Gobert, Internal Medicine Department, Hôpital Saint Antoine, 184 Rue Du Faubourg Saint Antoine, 75571 Paris Cedex 12, France (e-mail: )
| | - Romain Paule
- Hematology Department, Pitié Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University, Paris
| | - Denise Ponard
- Immunology Laboratory, University Hospital, Grenoble
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
| | - Pierre Levy
- Public Health Department, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University
| | - Véronique Frémeaux-Bacchi
- Immunology Laboratory, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris 5 University, Paris
| | - Laurence Bouillet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Joint Unit 1036 CNRS-CEA-INSERM, University Grenoble Alpes
- Internal Medicine Department, University Hospital, Grenoble
| | - Isabelle Boccon-Gibod
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Joint Unit 1036 CNRS-CEA-INSERM, University Grenoble Alpes
- Internal Medicine Department, University Hospital, Grenoble
| | - Christian Drouet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Université Joseph Fourier Grenoble, GREPI/AGIM CNRS FRE 3405, Grenoble
| | - Stéphane Gayet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Internal Medicine Department, La Conception Hospital, AP-HM, Marseille
| | - David Launay
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Internal Medicine and Clinical Immunology Department, Lille University Hospital
- LIRIC, INSERM UMR 995, EA2686, Lille
| | - Ludovic Martin
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Dermatology Department, L’UNAM Université, University Hospital, Angers, France
| | - Arsène Mekinian
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
| | - Véronique Leblond
- Hematology Department, Pitié Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University, Paris
| | - Olivier Fain
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
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Bekos C, Perkmann T, Krauth M, Raderer M, Lechner K, Jaeger U. Acquired C1 esterase inhibitor deficiency in lymphomas: prevalence, symptoms, and response to treatment. Leuk Lymphoma 2016; 57:2033-6. [PMID: 26795750 DOI: 10.3109/10428194.2015.1131273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We retrospectively studied the prevalence of C1 esterase inhibitor (C1 INH) deficiency in 131 patients with various lymphomas. We determined C1 INH activity, C1 INH antigen, and C4 concentration at diagnosis and after chemotherapy. In follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL) and chronic lymphocytic leukemia (CLL) consecutive patients were studied. In these entities, the prevalence of C1 INH deficiency was 10.2% in DLBCL, 4.1% in CLL, and 0% in FL and Hodgkin lymphoma. In indolent lymphomas, we identified only single cases of C1 INH deficiency, predominantly in splenic marginal zone lymphomas (SMZL) (four cases). Only three patients were symptomatic while the majority (11 cases) was asymptomatic. In DLBCL patients who were successfully treated with chemotherapy, complete normalization of C1 INH activity and C4 was observed. In contrast, C1 INH deficiency remained in SMZL patients after splenectomy. We conclude that C1 INH deficiency in lymphomas is frequently asymptomatic and responsive to immunochemotherapy.
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Affiliation(s)
- Christine Bekos
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Thomas Perkmann
- b Clinical Institute of Laboratory Medicine and Clinical Chemistry, Medical University of Vienna , Vienna , Austria
| | - Maria Krauth
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Markus Raderer
- c Department of Medicine I, Division of Clinical Oncology , Comprehensive Cancer Center, Medical University of Vienna , Vienna , Austria
| | - Klaus Lechner
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Ulrich Jaeger
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
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Castelli R, Wu MA, Arquati M, Zanichelli A, Suffritti C, Rossi D, Cicardi M. High prevalence of splenic marginal zone lymphoma among patients with acquired C1 inhibitor deficiency. Br J Haematol 2016; 172:902-8. [PMID: 26728240 DOI: 10.1111/bjh.13908] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/09/2015] [Indexed: 12/17/2022]
Abstract
Marginal zone lymphoma represents about 10% of all non-Hodgkin lymphomas (NHLs). 33% of patients with acquired angioedema (AAE) due to acquired C1-inhibitor (C1-INH) deficiency (C1-INH-AAE) have or will develop NHLs. C1-INH-AAE is a rare condition. We report the follow-up of 72 C1-INH-AAE patients, followed for a median of 15 years (range 1-24). Median age was 71 (range 64-79) years; median age at onset of angioedema symptoms was 57·5 (range 50-66) years and it was 63 [range 45-80) years at diagnosis]. Twenty patients were diagnosed with low-grade non-follicular B-cell lymphomas (75% were splenic MZL), one with follicular and three with high-grade lymphomas (two diffuse large B-cell lymphomas and one mantle cell lymphoma). Fifteen NHLs were diagnosed at onset of AAE or thereafter (3 months to 7 years), eight had already been diagnosed at onset of angioedema. Two of 24 patients remain on watchful wait. Thirthen of 24 received chemotherapy, two received rituximab. Three underwent splenectomy. All 18 patients receiving therapy for NHL experienced post-treatment reduction in AAE symptoms. Our study suggests that clonal B-cell proliferation is the pathology underlying AAE leading to production of C1-INH-neutralizing autoantibodies and to NHLs. The post-germinal centre origin of NHL suggests that immune stimulation may contribute to lymphomagenesis.
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Affiliation(s)
- Roberto Castelli
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Massimo Arquati
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Davide Rossi
- Division of Haematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
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Zeerleder S, Levi M. Hereditary and acquired C1-inhibitor-dependent angioedema: from pathophysiology to treatment. Ann Med 2016; 48:256-67. [PMID: 27018196 DOI: 10.3109/07853890.2016.1162909] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Uncontrolled generation of bradykinin (BK) due to insufficient levels of protease inhibitors controlling contact phase (CP) activation, increased activity of CP proteins, and/or inadequate degradation of BK into inactive peptides increases vascular permeability via BK-receptor 2 (BKR2) and results in subcutaneous and submucosal edema formation. Hereditary and acquired angioedema due to C1-inhibitor deficiency (C1-INH-HAE and -AAE) are diseases characterized by serious and potentially fatal attacks of subcutaneous and submucosal edemas of upper airways, facial structures, abdomen, and extremities, due to inadequate control of BK generation. A decreased activity of C1-inhibitor is the hallmark of C1-INH-HAE (types 1 and 2) due to a mutation in the C1-inhibitor gene, whereas the deficiency in C1-inhibitor in C1-INH-AAE is the result of autoimmune phenomena. In HAE with normal C1-inhibitor, a significant percentage of patients have an increased activity of factor XIIa due to a FXII mutation (FXII-HAE). Treatment of C1-inhibitor-dependent angioedema focuses on restoring control of BK generation by inhibition of CP proteases by correcting the balance between CP inhibitors and BK breakdown or by inhibition of BK-mediated effects at the BKR2 on endothelial cells. This review will address the pathophysiology, clinical picture, diagnosis and available treatment in C1-inhibitor-dependent angioedema focusing on BK-release and its regulation. Key Messages Inadequate control of bradykinin formation results in the formation of characteristic subcutaneous and submucosal edemas of the skin, upper airways, facial structures, abdomen and extremities as seen in hereditary and acquired C1-inhibitor-dependent angioedema. Diagnosis of hereditary and acquired C1-inhibitor-dependent angioedema may be troublesome as illustrated by the fact that there is a significant delay in diagnosis; a certain grade of suspicion is therefore crucial for quick diagnosis. Submucosal edema formation in hereditary and acquired C1-inhibitor-dependent angioedema is potentially life threatening and can occur at any age. To date effective therapies for acute and prophylactic treatment are available.
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Affiliation(s)
- Sacha Zeerleder
- a Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the AMC , Amsterdam , The Netherlands ;,b Department of Hematology , Academic Medical Center, University of Amsterdam , The Netherlands
| | - Marcel Levi
- c Department of Internal Medicine , Academic Medical Center, University of Amsterdam , The Netherlands
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31
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Patel S, Patel R, Draikiwicz S, Capitle E. Peripheral T-cell lymphoma: a challenging mimicker of angioedema and urticaria. Ann Allergy Asthma Immunol 2015; 115:94-5. [PMID: 26250768 DOI: 10.1016/j.anai.2015.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/15/2015] [Accepted: 06/17/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Shreya Patel
- Rutgers-New Jersey Medical School, Newark, New Jersey.
| | - Reenal Patel
- Rutgers-New Jersey Medical School, Newark, New Jersey
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32
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Fatal laryngeal angioedema: a case report and a workup of angioedema in a forensic setting. Forensic Sci Med Pathol 2015; 11:558-63. [PMID: 26242774 DOI: 10.1007/s12024-015-9701-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2015] [Indexed: 10/23/2022]
Abstract
Angioedema is an episodic swelling of the deep dermis, subcutis, and/or submucosal tissue due to an increase in local vascular permeability. Swelling may involve skin, respiratory, and gastrointestinal tracts. The most commonly involved areas are the periorbital region and the lips. Here we report a case of a fatal laryngeal obstruction due to angioedema likely caused by an angiotensin-converting-enzyme inhibitor. The decedent, a 58-year-old man, was witnessed developing sudden facial swelling and acute respiratory difficulties quickly followed by unresponsiveness. His past medical history suggested that this was his second episode of angioedema without urticaria. Postmortem examination revealed a complete laryngeal obstruction in the absence of infection, neoplasm, or autoimmune disease. Postmortem computed tomography of the head and neck showed a complete obstruction of the upper airway. Based on the current understanding of the pathophysiology of different types of angioedema, we will suggest a workup of angioedema without urticaria in the forensic setting and offer readers resources they can use in their practice.
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33
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[Dermatological manifestations of monoclonal gammopathies: contribution of cutaneous histopathology]. Ann Pathol 2015; 35:281-93. [PMID: 26188671 DOI: 10.1016/j.annpat.2015.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 05/06/2015] [Indexed: 12/19/2022]
Abstract
Skin manifestations associated with monoclonal gammapathy are common and can present with various clinical and pathological aspects. They can be the first events leading to the diagnosis of monoclonal gammapathy. They may be present either as specific lesions, including lymphoplasmacytic or pure plasma cell neoplastic infiltrates and monoclonal immunoglobulin deposits, or as non-specific dermatitis, such as leukocytoclastic vasculitis, neutrophilic dermatoses, mucinoses or xanthomatosis, giving little clues for the diagnosis of the underlying disease.
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34
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Blanc C, Togarsimalemath SK, Chauvet S, Le Quintrec M, Moulin B, Buchler M, Jokiranta TS, Roumenina LT, Fremeaux-Bacchi V, Dragon-Durey MA. Anti-factor H autoantibodies in C3 glomerulopathies and in atypical hemolytic uremic syndrome: one target, two diseases. THE JOURNAL OF IMMUNOLOGY 2015; 194:5129-38. [PMID: 25917093 DOI: 10.4049/jimmunol.1402770] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/31/2015] [Indexed: 02/06/2023]
Abstract
Autoantibodies targeting factor H (FH), which is a main alternative complement pathway regulatory protein, have been well characterized in atypical hemolytic uremic syndrome (aHUS) but have been less well described in association with alternative pathway-mediated glomerulopathies (GP). In this study, we studied 17 patients presenting with GP who were positive for anti-FH IgG. Clinical data were collected and biological characteristics were compared with those of patients presenting with anti-FH Ab-associated aHUS. In contrast to the aHUS patients, the GP patients had no circulating FH-containing immune complexes, and their anti-FH IgG had a weaker affinity for FH. Functional studies demonstrated that these Abs induced no perturbations in FH cell surface protection or the binding of FH to its ligand. However, anti-FH IgG samples isolated from three patients were able to affect the factor I cofactor activity of FH. Epitope mapping identified the N-terminal domain of FH as the major binding site for GP patient IgG. No homozygous deletions of the CFHR1 and CFHR3 genes, which are frequently associated with the anti-FH Ab in aHUS patients, were found in the GP patients. Finally, anti-FH Abs were frequently associated with the presence of C3 nephritic factor in child GP patients and with monoclonal gammopathy in adult GP patients, who frequently showed Ig Lchain restriction during reactivity against factor H. These data provide deeper insights into the pathophysiological differences between aHUS and GP, demonstrating heterogeneity of anti-FH IgG.
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Affiliation(s)
- Caroline Blanc
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Université Paris Diderot, 75013 Paris, France
| | - Shambhuprasad Kotresh Togarsimalemath
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Service de Néphrologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75970 Paris Cedex 20, France
| | - Sophie Chauvet
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - Moglie Le Quintrec
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Service de Néphrologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75970 Paris Cedex 20, France
| | - Bruno Moulin
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalier Universitaire Hautepierre, 67098 Strasbourg, France
| | - Matthias Buchler
- Service de Néphrologie, Immunologie Clinique, Hôpital Bretonneau, 37044 Tours, France
| | - T Sakari Jokiranta
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, 00014 Helsinki, Finland; and
| | - Lubka T Roumenina
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France
| | - Véronique Fremeaux-Bacchi
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75908 Paris, France
| | - Marie-Agnès Dragon-Durey
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Service de Néphrologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75970 Paris Cedex 20, France; Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75908 Paris, France
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Pedrosa M, Prieto-García A, Sala-Cunill A, Baeza ML, Cabañas R, Campos A, Cimbollek S, Gómez-Traseira C, González Quevedo T, Guilarte M, Jurado-Palomo J, Lobera T, López-Serrano MC, Marcos C, Piñero-Saavedra M, Prior N, Sáenz de San Pedro B, Ferrer M, Barceló JM, Daschner A, Echechipía M, Garcés M, Iriarte P, Jáuregui I, Lázaro M, Quiñones M, Veleiro B, Villareal O. Management of angioedema without urticaria in the emergency department. Ann Med 2014; 46:607-18. [PMID: 25580506 DOI: 10.3109/07853890.2014.949300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.
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Affiliation(s)
- Maria Pedrosa
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.
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Shepshelovich D, Diker-Cohen T, Lahav M. Searching for the leak. Am J Hematol 2014; 89:928-30. [PMID: 24850307 DOI: 10.1002/ajh.23763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/14/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Daniel Shepshelovich
- Medicine A; Rabin Medical Center, Beilinson Campus; Petah-Tikva Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Talia Diker-Cohen
- Medicine A; Rabin Medical Center, Beilinson Campus; Petah-Tikva Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
- Diabetes, Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health; Bethesda Maryland
| | - Meir Lahav
- Medicine A; Rabin Medical Center, Beilinson Campus; Petah-Tikva Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
- Institute of Hematology; Davidoff Center, Rabin Medical Center, Beilinson Campus; Petah-Tikva Israel
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Gunatilake SSC, Wimalaratna H. Angioedema as the first presentation of B-cell non-Hodgkin lymphoma--an unusual case with normal C1 esterase inhibitor level: a case report. BMC Res Notes 2014; 7:495. [PMID: 25099363 PMCID: PMC4266895 DOI: 10.1186/1756-0500-7-495] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/29/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Acquired angioedema is a rare but recognized manifestation of lymphoproliferative disorders due to deficiency in C1 esterase inhibitor. Normal level of C1 esterase inhibitor proteins in association with angioedema due to lymphoproliferative disease is a rare and an uncommon finding caused by antibodies produced from the underlying disease. Antibodies cause inactivation of C1 esterase inhibitor, thus resulting in C1 esterase inhibitor dysfunction despite of normal quantity of C1 esterase inhibitor. CASE PRESENTATION A 50-year-old Sri Lankan male presented with first episode of angioedema without any family history. Physical examination revealed mild pallor with swelling of tongue, lips and perioral region. On investigations, erythrocyte sedimentation rate was persistently high and bone marrow with immunohistochemistry revealed infiltration with B-cell type low grade non-Hodgkin lymphoma. Computed tomography scan of the chest and abdomen showed paratracheal and subcarinal lymphadenopathy and splenomegaly, with the findings being compatible with lymphoma. He had normal C1 esterase inhibitor protein level with reduced activity and low C1q, C4 levels indicating antibodies against C1 esterase inhibitor causing dysfunctional C1 esterase inhibitor. CONCLUSION Adult onset angioedema should prompt physicians to suspect underlying lymphoproliferative disorder despite of C1 esterase inhibitor protein level being normal. Though uncommon, presence of antibodies against C1 esterase inhibitor secondary to lymphoproliferative disorder should be considered in the presence of normal C1 esterase inhibitor protein levels with low functional capacity in the background of acquired angioedema.
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38
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Lara-Jiménez MA, Ruiz-Rivera L, Magro-Checa C. Acquired angioedema with C1 inhibitor deficiency secondary to splenic marginal zone B-cell lymphoma. Rev Clin Esp 2014; 214:e107-9. [PMID: 24970460 DOI: 10.1016/j.rce.2014.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
Affiliation(s)
- M A Lara-Jiménez
- Unidad de Alergología, Unidad de Gestión Clínica Medicina Interna, Hospital Universitario San Cecilio, Granada, España.
| | - L Ruiz-Rivera
- Unidad de Gestión Clínica Medicina Interna, Hospital Universitario San Cecilio, Granada, España
| | - C Magro-Checa
- Departamento de Reumatología, Hospital Universitario San Cecilio, Granada, España
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Cicardi M, Aberer W, Banerji A, Bas M, Bernstein JA, Bork K, Caballero T, Farkas H, Grumach A, Kaplan AP, Riedl MA, Triggiani M, Zanichelli A, Zuraw B. Classification, diagnosis, and approach to treatment for angioedema: consensus report from the Hereditary Angioedema International Working Group. Allergy 2014; 69:602-16. [PMID: 24673465 DOI: 10.1111/all.12380] [Citation(s) in RCA: 428] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 01/13/2023]
Abstract
Angioedema is defined as localized and self-limiting edema of the subcutaneous and submucosal tissue, due to a temporary increase in vascular permeability caused by the release of vasoactive mediator(s). When angioedema recurs without significant wheals, the patient should be diagnosed to have angioedema as a distinct disease. In the absence of accepted classification, different types of angioedema are not uniquely identified. For this reason, the European Academy of Allergy and Clinical Immunology gave its patronage to a consensus conference aimed at classifying angioedema. Four types of acquired and three types of hereditary angioedema were identified as separate forms from the analysis of the literature and were presented in detail at the meeting. Here, we summarize the analysis of the data and the resulting classification of angioedema.
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Affiliation(s)
- M. Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - W. Aberer
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - A. Banerji
- Division of Rheumatology, Allergy and Immunology; Massachusetts General Hospital; Boston MA USA
| | - M. Bas
- Department of Otorhinolaryngology; Klinikum rechts der Isar; Technische Universität München; Munich Germany
| | - J. A. Bernstein
- Division of Immunology/Allergy Section; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - T. Caballero
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPaz); Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - H. Farkas
- 3rd Department of Internal Medicine; National Angioedema Center; Semmelweis University; Budapest Hungary
| | - A. Grumach
- Department of Clinical Medicine; Faculty of Medicine ABC; Sao Paulo Brazil
| | - A. P. Kaplan
- Medical University of South Carolina; Charleston SC
| | - M. A. Riedl
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
| | - M. Triggiani
- Department of Medicine; University of Salerno; Salerno Italy
| | - A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - B. Zuraw
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
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Tohani A, Chua I, Grigoriadou S, Buckland MS, Longhurst HJ. Acquired C1 inhibitor deficiency: should we monitor for associated antibody deficiency? Ann Allergy Asthma Immunol 2014; 112:265-7. [PMID: 24565597 DOI: 10.1016/j.anai.2013.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 12/24/2013] [Accepted: 12/30/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Arun Tohani
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England
| | - Ignatius Chua
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England
| | - Sofia Grigoriadou
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England
| | - Matthew S Buckland
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England
| | - Hilary J Longhurst
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England.
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Defendi F, Charignon D, Ghannam A, Baroso R, Csopaki F, Allegret-Cadet M, Ponard D, Favier B, Cichon S, Nicolie B, Fain O, Martin L, Drouet C. Enzymatic assays for the diagnosis of bradykinin-dependent angioedema. PLoS One 2013; 8:e70140. [PMID: 23940538 PMCID: PMC3734293 DOI: 10.1371/journal.pone.0070140] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 06/20/2013] [Indexed: 01/11/2023] Open
Abstract
Background The kinins (primarily bradykinin, BK) represent the mediators responsible for local increase of vascular permeability in hereditary angioedema (HAE), HAE I-II associated with alterations of the SERPING1 gene and HAE with normal C1-Inhibitor function (HAE-nC1INH). Besides C1-Inhibitor function and concentration, no biological assay of kinin metabolism is actually available to help physicians for the diagnosis of angioedema (AE). We describe enzymatic tests on the plasma for diagnosis of BK-dependent AE. Methods The plasma amidase assays are performed using the Pro-Phe-Arg-p-nitroanilide peptide substrate to evaluate the spontaneous amidase activity and the proenzyme activation. We analyzed data of 872 patients presenting with BK-dependent AE or BK-unrelated diseases, compared to 303 controls. Anti-high MW kininogen (HK) immunoblot was achieved to confirm HK cleavage in exemplary samples. Reproducibility, repeatability, limit of blank, limit of detection, precision, linearity and receiver operating characteristics (ROC) were used to calculate the diagnostic performance of the assays. Results Spontaneous amidase activity was significantly increased in all BK-dependent AE, associated with the acute phase of disease in HAE-nC1INH, but preserved in BK-unrelated disorders. The increase of the amidase activity was associated to HK proteolysis, indicating its relevance to identify kininogenase activity. The oestrogens, known for precipitating AE episodes, were found as triggers of enzymatic activity. Calculations from ROC curves gave the optimum diagnostic cut-off for women (9.3 nmol⋅min−1⋅mL−1, area under curve [AUC] 92.1%, sensitivity 80.0%, and specificity 90.1%) and for men (6.6 nmol·min−1⋅mL−1, AUC 91.0%, sensitivity 87.0% and specificity 81.2%). Conclusion The amidase assay represents a diagnostic tool to help physicians in the decision to distinguish between BK-related and –unrelated AE.
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Affiliation(s)
- Federica Defendi
- Centre de Référence des Angioedèmes à Kinines, CREAK, Grenoble, France.
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Manson AL, Price A, Dempster J, Clinton-Tarestad P, Greening C, Enti R, Hill S, Grigoriadou S, Buckland MS, Longhurst HJ. In pursuit of excellence: an integrated care pathway for C1 inhibitor deficiency. Clin Exp Immunol 2013; 173:1-7. [PMID: 23607500 PMCID: PMC3694529 DOI: 10.1111/cei.12083] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2013] [Indexed: 01/22/2023] Open
Abstract
There are estimated to be approximately 1500 people in the United Kingdom with C1 inhibitor (C1INH) deficiency. At BartsHealth National Health Service (NHS) Trust we manage 133 patients with this condition and we believe that this represents one of the largest cohorts in the United Kingdom. C1INH deficiency may be hereditary or acquired. It is characterized by unpredictable episodic swellings, which may affect any part of the body, but are potentially fatal if they involve the larynx and cause significant morbidity if they involve the viscera. The last few years have seen a revolution in the treatment options that are available for C1 inhibitor deficiency. However, this occurs at a time when there are increased spending restraints in the NHS and the commissioning structure is being overhauled. Integrated care pathways (ICP) are a tool for disseminating best practice, for facilitating clinical audit, enabling multi-disciplinary working and for reducing health-care costs. Here we present an ICP for managing C1 inhibitor deficiency.
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Affiliation(s)
- A L Manson
- Department of Immunopathology, Barts Health NHS Trust, London, UK
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Castelli R, Zanichelli A, Cicardi M, Cugno M. Acquired C1-inhibitor deficiency and lymphoproliferative disorders: a tight relationship. Crit Rev Oncol Hematol 2013; 87:323-32. [PMID: 23490322 DOI: 10.1016/j.critrevonc.2013.02.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/11/2013] [Accepted: 02/14/2013] [Indexed: 11/18/2022] Open
Abstract
Angioedema due to the acquired deficiency of C1-inhibitor is a rare disease known as acquired angioedema (AAE), which was first described in a patient with high-grade lymphoma and is frequently associated with lymphoproliferative diseases, including expansion of B cell clones producing anti-C1-INH autoantibodies, monoclonal gammopathy of uncertain significance (MGUS) and non-Hodgkin lymphoma (NHL). AAE is clinically similar to hereditary angioedema (HAE), and is characterized by recurrent episodes of sub-cutaneous and sub-mucosal edema. It may affect the face, tongue, extremities, trunk and genitals. The involvement of the gastrointestinal tract causes bowel sub-occlusion with severe pain, vomiting and diarrhea, whereas laryngeal edema can be life-threatening. Unlike those with HAE, AAE patients usually have late-onset symptoms, do not have a family history of angioedema and present variable response to treatment due to the hyper-catabolism of C1-inhibitor. Reduced C1-inhibitor function leads to activation of the classic complement pathway with its consumption and activation of the contact system leading to the generation of the vasoactive peptide bradykinin, which increases vascular permeability and induces angioedema. Lymphoprolipherative diseases and AAE are tightly linked with either angioedema or limphoprolyferation being the first symptom. Experimental data indicate that neoplastic tissue and/or anti-C1-inhibitor antibodies induce C1-inhibitor consumption, and this is further supported by the observation that cytotoxic treatment of the lymphoproliferative diseases associated with AAE variably reverses the complement impairment and leads to a clinical improvement in angioedema symptoms.
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Affiliation(s)
- Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, Italy
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Mohyuddin G, Rabinowitz I. A patient with chronic lymphocytic leukemia and acquired angioedema: correlation of clinical and biochemical response to CLL therapy. Ecancermedicalscience 2013; 7:292. [PMID: 23441138 PMCID: PMC3575201 DOI: 10.3332/ecancer.2013.292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Indexed: 11/06/2022] Open
Abstract
Acquired angioedema (AAE) is a result of an acquired deficiency or inactivity of the C1 esterase inhibitor (C1-INH). There is a well-known link between AAE and lymphoplasmacytic disorders.A 65-year-old woman who was diagnosed with chronic lymphocytic leukemia (CLL), presented with recurrent episodes of angioedema. Although no association between the CLL and angioedema was initially recognized, further workup showed her to have low C1-INH levels. Chemotherapy helped prevent subsequent episodes, but three years later she redeveloped angioedema. She was then placed on ofatumumab maintenance and has since remained free of angioedema.Knowledge of this rare disease and anticipation of the link between CLL and AAE can prevent further attacks and associated morbidity.
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Affiliation(s)
- Gr Mohyuddin
- University of New Mexico Cancer Center, 1201 Camino de Salud NE, Albuquerque, NM 87131, USA
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Castelli R, Zanichelli A, Cugno M. Therapeutic options for patients with angioedema due to C1-inhibitor deficiencies: from pathophysiology to the clinic. Immunopharmacol Immunotoxicol 2012; 35:181-90. [DOI: 10.3109/08923973.2012.726627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Giard C, Nicolie B, Drouet M, Lefebvre-Lacoeuille C, Le Sellin J, Bonneau JC, Maillard H, Rénier G, Cichon S, Ponard D, Drouet C, Martin L. Angio-oedema induced by oestrogen contraceptives is mediated by bradykinin and is frequently associated with urticaria. Dermatology 2012; 225:62-9. [PMID: 22922353 DOI: 10.1159/000340029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 06/04/2012] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hereditary C1-inhibitor (C1-Inh) deficiency is associated with 'bradykinin-mediated angio-oedema' (BK-AO) and is believed not to be associated with urticaria. Acquired AO has been related to oestrogen contraceptives. OBJECTIVE To demonstrate that AO precipitated by oestrogens and characterized by nonfunctional C1-Inh is mediated by BK and to evaluate the occurrence of urticaria in these patients. METHODS A retrospective evaluation of patients referred for AO related to oestrogen was undertaken. Circulating C1-Inh, high molecular weight kininogen (HK) and enzymes involved in the metabolism of bradykinin were investigated. RESULTS Fifteen patients were included. HK cleavage concurrent to oestrogen intake was demonstrated in 10 patients with available plasma. Eight patients reported recurrent or chronic urticaria. Discontinuation of the contraceptive resulted in a return to native C1-Inh and HK in all cases studied and to normal kininogenase activity in all but one. The clinical manifestations completely disappeared in 6 patients and improved in 7 after the withdrawal of oestrogen. CONCLUSION Patients display extensive cleavage of HK in the plasma, which supports that AO precipitated by oestrogen contraception is BK-mediated. Recurrent urticaria may have been underestimated in this context. The presence of recurrent urticaria should not systematically rule out the diagnosis of BK-AO when the history is suggestive.
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Affiliation(s)
- C Giard
- Department of Dermatology, L’UNAM University, Angers Hospital, Angers, France
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Acquired C1-inhibitor deficiency: 7 patients treated with rituximab. J Clin Immunol 2012; 32:936-41. [PMID: 22526593 DOI: 10.1007/s10875-012-9691-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 03/30/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Acquired C1-inhibitor deficiency can occur secondary to excessive C1-inhibitor consumption (type I) and be associated with a lymphoid hemopathy, or linked to the presence of anti-C1-inhibitor autoantibodies (type II) in a context of an isolated monoclonal gammopathy, sometimes associated with lymphoproliferation. Efficacy of danazol, tranexamic acid and/or corticosteroids is inconstant. Rituximab efficacy against type II angioedema has been reported. METHODS Description of 7 rituximab-treated patients, 6 with type II acquired angioedema and 1 with type I. RESULTS Clinical efficacy (only for type II) was complete for 3, partial for 2 and 2 were therapeutic failures. Only 2 patients had improved biological parameters, with normalization of their C1-inhibitor levels and diminished anti-C1-inhibitor autoantibodies, observed 1-9 months after the last infusion of the second rituximab cycle. An associated lymphoproliferation did not affect the response to treatment. CONCLUSION Rituximab efficacy in the treatment of acquired angioedema is inconstant and might require repeated cycles.
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Jung M, Rice L. "Surgical" abdomen in a patient with chronic lymphocytic leukemia: a case of acquired angioedema. J Gastrointest Surg 2011; 15:2262-6. [PMID: 21997434 PMCID: PMC3220812 DOI: 10.1007/s11605-011-1718-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 02/23/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Acquired angioedema (AAE), an acquired deficiency of C1esterase inhibitor, is a medically treatable condition which can cause severe abdominal pain mimicking an acute surgical abdomen. This disorder is strongly associated with chronic lymphocytic leukemia (CLL) and other indolent lymphoplasmacytic disorders. DISCUSSION We describe a patient with known CLL who developed incapacitating, recurrent severe abdominal pains, culminating in partial bowel resection. Signs, symptoms, laboratory and pathologic findings demonstrated AAE. CONCLUSION Wider appreciation of the possibility of AAE, particularly in patients with lymphoproliferative disorders, could lead to preventive therapy and spare unnecessary surgery. This is more important now that more effective medical therapies are available.
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Affiliation(s)
- Moonjung Jung
- Department of Medicine, The Methodist Hospital, Weill Cornell Medical College, 6550 Fannin Street, #1001, Houston, TX 77030 USA
| | - Lawrence Rice
- Department of Medicine, The Methodist Hospital, Weill Cornell Medical College, 6550 Fannin Street, #1001, Houston, TX 77030 USA
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